SEATBELTS ARE CARCINOGENIC!

or

The Creation of New Modes of Aging and Dying:

Societal Implications

  James Hallenbeck, MD

Topics of Discussion

• How we have created new modes of aging and dying

• Trying to fill the cultural gap of modern dying

• A look to the future…• System implications • Personal Implications• Gender-related issues

Key arguments

• We are still mortal• All probabilities must add up to 100%

– Eliminating one cause of death increases the probability of other causes

• How we die has changed radically• Dying as a cultural activity is conservative• A cultural gap in how we die has been created• We are headed toward a major crisis

Changes in How We Die

• Most deaths now in institutions– Families less able to care for dying patients

• Most deaths due to chronic illness• Dying usually takes a long time• Dying is expensive• Many options available

– Treatments, care systems, where to die

Many now view dying itself as a choice

Top 5 Causes of Death 1900

Rank Cause of Death Percentage

1 Influenza,Pneumonia

11.8

2 Tuberculosis 11.3

3 Gastritis,Enteritis

8.3

4 Heart Disease 8.0

5 Stroke 6.2

Top 5 Causes of Death 1994

Rank Cause of Death Percentage

1 Heart Disease 32.1

2 Cancer 23.5

3 Stroke 6.8

4 COPD 4.5

5 Accidents 3.9

Where Do We Die

60%20%

20%

OtherNursing HomeHospital

Care for the Dying Is Expensive

• 2.3 million Americans die annually

• Expense of care for the dying: 45 billion/year for last six months of life– 7.5% of healthcare expenditures for 0.9% of

population

• Dying is largely publicly funded– However 30% of families impoverished by

private expenditures for dying

Dying Takes a Long Time

• From brief transition period to LIFE STAGE

• Social Implications – new systems needed• Cultural Implications – meaning of stage

and relation to other life stages• Personal Implications- what is to be

accomplished in dying?

When does dying begin?

Culture of BiomedicineTensions

• Individualism– Autonomy

– Disease in the individual

– Consumerism

• Egalitarianism – Health care as a right

• Mechanistic/technologic – Reductionist

– Paternalistic

– Bureaucratic

• Capitalism– Health care as commodity

Lacking in modern biomedicineFocus on suffering as object of medicine

Inclusion of concept of “life-force” in modelUnderstanding illness as something transcending the individual

Suffering andOpportunity

• New forms of suffering – Pain and other symptoms– Economic hardship– Loss of control– Existential and Spiritual

What new opportunities for growth and transcendence arise from such suffering?

Predictions

• Health care expenditures as % GDP will continue to grow

• Ratio of Elders in need of care / Available Caregivers will grow dramatically

• Continuing shift in locus of care for chronically ill patients out of hospital and into the community

Implications if Prediction Accurate

• “De-medicalization” of chronic illness and dying• A further shift in care burden to families and

communities unprepared and unable to accept such a burden

• A caregiver crisis– Families unable to provide care

– Inadequate number of professional caregivers (poor, minorities and immigrants)

The Disproportionate Burden onWomen

• Women much more likely to be caregivers– of husbands– of parents and parents-in-law: often while

employed and raising children

• Women less likely to have caregivers– As more likely to survive spouse– Men less willing to take-on caregiving roles

Something Has to Give

• Reconstitution of nuclear families, traditional roles (unlikely)

• Massive caregiver immigration (possible) • Legalization and sanctioning of assisted

suicide (likely)• A new wave of institutionalization (very

likely)

Possibilities…

Moral(s) of the Story

• Dying at home will continue to be the exception, not the rule and a privilege of the rich

• National health care initiatives are unlikely to ‘save us’

• We must take both personal and community responsibility for how we will age and die

Can we create new institutions to meet our changing needs?